Finding into death of JP

Contributing factors

• inadequate frequency of consultant psychiatrist review in 11 days prior to transfer
• access to sharps container during escorted leave
• difficulty maintaining intravenous access due to patient aggression and refusal
• severe focal coronary artery atherosclerosis (80% luminal occlusion) that may have interacted with septic shock
• underlying severe mental illness with complex self-harm history

Coroner's recommendations

1. NorthWestern Mental Health to improve clarity of requirements for regular consultant psychiatrist review of all inpatients by writing a procedure with compliance audited as part of regular file audits
2. NorthWestern Mental Health to ensure each patient in the mental health acute psychiatric unit is reviewed by a consultant psychiatrist a minimum of twice per week where feasible
3. Implement clinical escalation guidelines for the Continuing Community Care Unit, Community Mental Health Teams and Inpatient Units
4. Restructure operational management of inpatient units and establish Nurse Unit managers for each 25-bed unit
5. Increase consultant psychiatrist staffing complement (0.6 EFT added at cost of approximately $180,000)